1285609883 NPI number — DR. MONICA JANE HARDEE MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285609883 NPI number — DR. MONICA JANE HARDEE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARDEE
Provider First Name:
MONICA
Provider Middle Name:
JANE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHAFFER
Provider Other First Name:
MONICA
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285609883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1136 E GRANDE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75703-3982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-592-5601
Provider Business Mailing Address Fax Number:
903-595-3304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1136 E GRANDE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-3982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-592-5601
Provider Business Practice Location Address Fax Number:
903-595-3304
Provider Enumeration Date:
02/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  L6628 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 159491304 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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